GABRIEL LEESE DERSAM MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****21

License Status

NOT RENEWED

Business

Title

First Name

GABRIEL

Middle

LEESE

Last Name

DERSAM

Business Name

GABRIEL LEESE DERSAM MD

Original Issue Date

10/16/2014

Effective Date

10/16/2014

Expiration Date

07/31/2017

City

PEORIA

State

Zip

61637

County

PEORIA

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/01/2017